Fertility Center:*

Address:*

City:*

State:*
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Zip:*

Phone:*

Fax:

Date:*

From:*

RN or IVF:*
RN
IVF

First Name:*

Last Name:*

DOB:*

Home #:

Work #:

Cell #:

Treatment:
Ovulation Induction
IVF

Patient is a ...?
Donor
Recipient

Bravelle 75IU Vial

Sig:

Qty

Refills

Follistim™ AQ 75IU Vials

Sig:

Qty

Refills

Follistim™ AQ 150IU Vials

Sig:

Qty

Refills

Follistim™ AQ Cartridges 300 IU

Sig:

Qty

Refills

Follistim™ AQ Cartridges 600IU

Sig:

Qty

Refills

Follistim™ AQ Cartridges 900IU

Sig:

Qty

Refills

Gonal-F® RFF 75IU Vial

Sig:

Qty

Refills

Gonal-F® 450IU Multi-dose Kit

Sig:

Qty

Refills

Gonal-F® RFF Pen 300IU

Sig:

Qty

Refills

Gonal-F® RFF Pen 450IU

Sig:

Qty

Refills

Gonal-F® RFF Pen 900IU

Sig:

Qty

Refills

Luveris® 75IU Vial

Sig:

Qty

Refills

Menopur® 75IU Vial

Sig:

Qty

Refills

Novarel® 75IU Vial

Sig:

Qty

Refills

Pregnyl® 75IU Vial

Sig:

Qty

Refills

Repronex® 75IU Vial

Sig:

Qty

Refills

HCG 10,000IU Vial

Sig:

Qty

Refills

Ovidrel Prefilled Syringes 250mcg

Sig:

Qty

Refills

Sharps Package - No Charge
(Sharps disposal unit, alcohol wipes, gauze, disposal instructions, inc.)

3cc 22g 1½" Needle & Syringe

Qty

Refills

18g 1½" Needles

Qty

Refills

25g 1 ½" Needles

Qty

Refills

25g 1" Needles

Qty

Refills

25g 5/8" Needles

Qty

Refills

22g 1" Needles

Qty

Refills

3 cc Syringe

Qty

Refills

1 cc Syringe

Qty

Refills

½ cc Syringe

#

Refills

Follistim Pen

#

Refills

Air-tite Syringe (Normject)

#

Refills

Other:

Product Name

#

Refills

Syringes and needles will NOT be dispensed unless indicated

Antagon/Ganirelix Prefilled Syringes -- 250UG/0.5ml

Sig:

Qty

Refills

Cetrotide:

Dose:
0.25mg
3mg

Sig:

Qty

Refills

Lupron 2-Week Kit

Leuprolide 2 Week Kit (generic)

Extra Lupron Syringes to be refilled only after request by patient

Sig:

Qty

Refills

Lupron Microdose:

Dose:

Sig:

Qty

Refills

Progesterone in Sesame Oil-50mg/ml 10ml Vial

Sig:

Qty

Refills

Progesterone Capsules:

Dose:

Sig:

Qty

Refills

Progesterone Suppositories

Dose:

Sig:

Qty

Refills:

Prometrium Capsules 200mg

Sig:

Qty

Refills

Clomiphene Citrate 50mg

Sig:

Qty

Refills

Doxycyline 100mg

Sig:

Qty

Refills

Estrace®

Dose:

Sig:

Qty

Refills

Medrol 16mg

Sig:

Qty

Refills

Endometrin 100mg

Sig:

Qty

Refills

Other:

Product Name

Sig:

Qty

Refills

Other:

Product Name

Sig:

Qty

Refills

Anticipated Start Date:

Physician's Signature:

Interchange is mandated unless practitioner writes the words "NO SUBSTITUTIONS" in this space.

Physician's Name:

Physicians Phone #:

DEA#:

NPI#: